Form Ft-500 - Application For Refund Of Sales Tax Paid On Petroleum Products (Page 2 of 3) in pdf

Form Ft-500 - Application For Refund Of Sales Tax Paid On Petroleum Products Page 2

Page 2 of 3 FT-500 (9/11)

9. Mark an X in this box if you are filing this sales tax refund form together with a refund form for motor/diesel motor fuel tax

or petroleum business tax for the same period. Attach invoices or other information as required by all forms and mail all

forms in one envelope. ...........................................................................................................................................................

Certification: I,

, the applicant named above, or partner, officer, or other authorized

representative of such applicant, do hereby:

• make application for refund of tax, pursuant to the New York State Tax Law; and

• certify that the above statements, and any documents provided to substantiate the refund claimed, are true, complete and

correct and that no material information has been omitted; and

• certify that all of the tax for which this claim is filed has been paid, and no portion has been previously credited or refunded

to the applicant by any person required to collect tax; or, if the claim for refund is made by a person required to collect tax,

that the amount claimed has not previously been refunded to the appropriate purchaser; and

• certify that no amount claimed has previously been subject to a credit or refund; and

• make these statements with the knowledge that willfully providing false or fraudulent information with this document with

the intent to evade tax may constitute a felony or other crime under New York State Law, punishable by a substantial fine

and a possible jail sentence; and

• understand that the Tax Department is authorized to investigate the validity of the refund claimed and the accuracy of any

information provided with this claim.

Signature of authorized person

Official title

Authorized

person

E-mail address of authorized person

Telephone number

Date

(

)

Firm’s name

Firm’s EIN

Preparer’s PTIN or SSN

(or yours if self-employed)

Paid

preparer

Signature of individual preparing this return

Address

City

State

ZIP code

use

only

E-mail address of individual preparing this return

Telephone number

Preparer’s NYTPRIN

Date

(see instr.)

(

)

Form Ft-500 - Application For Refund Of Sales Tax Paid On Petroleum Products Page 2

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